Know Your Insurance Rights

You have rights, no matter what type of insurance you have. Knowing these rights will help you get the treatment you’re entitled to. Here are some of the basics:

Affordable Care Act (ACA) prohibits insurance companies from denying you coverage based on a pre-existing condition and creates Marketplaces (one-stop shops through which you can search and choose a health insurance plan) as a way to get coverage.

Consolidated Omnibus Budget Reconciliation Act (COBRA) allows you to keep your health insurance policy if you are losing or changing jobs. If a private, state or local government employer has at least 20 employees and offers a group health plan, COBRA requires that the employer offer employees, their families and retirees an opportunity to keep their health insurance at group rates after leaving the company or reducing the number of hours they work. If you stop work, you can maintain your group coverage for 18 months, but you must notify your employer within 60 days of the qualifying event that you wish to elect COBRA.

You will have to pay both your share and your employer’s share of the insurance premiums, plus two percent. Hence, COBRA can get very expensive over time because you do not have an employer supplementing the premium. There are resources available — like Caring Voice Coalition — to help pay those premiums and coinsurances. At the end of the 18-month period, you are allowed to enroll in an individual conversion health plan if your employer offers one.

Employment Retirement Income Security Act (ERISA) requires insurance providers to disclose plan benefits and funding levels, as well as how you can manage and access your benefits. ERISA governs private health insurance provided by self-insured institutions (employers or organizations that pay for medical bills out of their own funds). ERISA is a very complex law: it provides certain rights, such as the right to appeal a denial of benefits and a right to judicial remedies (financial or other forms of compensation as determined by a court of law). If your employer does not self-insure, but instead contracts with an insurance company, then your state’s laws and HIPAA (explained below) govern these matters instead.

Family and Medical Leave Act (FMLA) provides employees with the right to take time off to address family medical issues. This law applies to all private employers with 50 or more employees within a single state, state and local governments (including schools) and some federal employees. It says that an employer must allow up to 12 unpaid weeks of leave a year when various situations occur, such as a serious health condition that leaves the employee unable to work, or if a dependent of the employee has a serious medical condition that requires the employee to miss work in order to care for the dependent. Group health benefits must be continued during the leave. The law is enforced by the U.S. Department of Labor’s Employment Standards Administration, Wage and Hour Division.

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The information provided on the PHA website is provided for general information only. It is not intended as legal, medical or other professional advice, and should not be relied upon as a substitute for consultations with qualified professionals who are familiar with your individual needs. PHA does not endorse or recommend any commercial products or services.